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A 5 month male presents with a seizure. The patient had been sick with a fever for 1 day and then suddenly developed jerking of his left hand that progressed to tonic-clonic left sided movements. The child was still seizing when EMS arrived. Paramedics administered diastat and the seizure stopped. Estimated duration of the seizure was approximately 20 - 30 minutes. The child has had 2 month and 4 month immunizations. Vitals on arrival: Temp 103, HR 170, RR 20, BP 90/50. The child is very sleepy on exam. What work up is most appropriate for this child?

Nothing

UA and urine culture

CBC, blood cx, UA and urine culture

Labs, UA, urine culture and an LP

ANSWER:4. There are several features that are NOT consistent with a simple febrile seizure. 1) the seizure is > 15 minutes in length 2) the seizure is focal. 3) the patient is younger than the usual age for simple febrile seizures (6mo – 6 years). For all these reasons, consideration should be given to lumbar puncture. Given the focal nature of the seizure HSV should be high on the differential and starting acyclovir as well as sending an HSV pcr is highly recommended. Performing a head ct prior to LP should be done in any patient with signs of elevated intracranial pressure. PEARL:Simple febrile seizure = generalized, less than 15 minutes, age 6mo – 6 years.ARTICLE:Kimia A, Ben-joseph EP, Rudloe T, et al. Yield of lumbar puncture among children who present with their first complex febrile seizure. Pediatrics. 2010;126(1):62-9.ABSTRACTObjectiveTo assess the rate of acute bacterial meningitis (ABM) among children who present with their first complex febrile seizure (CFS).Design and MethodsThis study was a retrospective, cohort review of patients aged 6 to 60 months who were evaluated in a pediatric emergency department (ED) between 1995 and 2008 for their first CFS. Cases were identified by using a computerized text search followed by a manual chart review. Exclusion criteria included prior history of nonfebrile seizures, an immunocompromised state, an underlying illness associated with seizures or altered mental status, or trauma. Data extracted included age, gender, seizure features, the number of previous simple febrile seizures, temperature, a family history of seizures, findings on physical examination, laboratory and imaging study results, and ED diagnosis and disposition.ResultsWe identified 526 patients. The median age was 17 months (interquartile range: 13-24), and 44% were female. Ninety patients (17%) had a previous history of simple febrile seizures. Of the patients, 340 (64%) had a lumbar puncture (LP). The patients' median white blood cell count during a CFS was 1 cell per microL (interquartile range: 1-2), and 14 patients had CSF pleocytosis (2.7% [95% confidence interval [CI]: 1.5-4.5]). Three patients had ABM (0.9% [95% CI: 0.2-2.8]). Two had Streptococcus pneumoniae in a culture of their cerebrospinal fluid. Among these 2 patients, 1 was nonresponsive during presentation, and the other had a bulging fontanel and apnea. The third child appeared well; however, her blood culture grew S pneumoniae and failed the LP test. None of the patients for whom an LP was not attempted subsequently returned to the hospital with a diagnosis of ABM (0% [95% CI: 0, 0.9]).Conclusion Few patients who experienced a CFS had ABM in the absence of other signs or symptoms.

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